10.2009
Interlocuteur pour vos questions transfrontalières Ihr Ansprechpartner für grenzüberschreitende Fragen
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l u c i h é v s e d n o i t a l u c i r t a Imm DEMANDE DE CERTIFICAT D’IMMATRI Articles R. 322-1 et suivants du c Veuillez cocher la case corr
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FDuplicata FCorrection FChangement d’état civil ou d’état matrimonial FChangem VÉHICULE (A) Numéro d’immatriculation actuel
Date d’achat, le cas échéant
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Numéro de formule du certificat d’immatriculation * (si nouveau format d’immatriculation)
DEMANDEUR Personne physique F
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a F h r s z e eugs n i e g n u d l e m Um Vos démarches relatives à l’immatriculation en France d’un véhicule acheté en Allemagne
Ihre Behördengänge bei der Ummeldung eines in Deutschland erworbenen Fahrzeugs nach Frankreich
Editeur / Herausgeber SIVOM Pays de Brisach
En coopération avec / In Zusammenarbeit mit Préfecture du Haut-Rhin 7 rue Bruat BP 10489 - F-68020 Colmar Cedex http://haut-rhin.pref.gouv.fr Landratsamt Breisgau-Hochschwarzwald Stadtstraße 2 D-79104 Freiburg i. Br. http://www.breisgau-hochschwarzwald.de
Rédaction / Redaktion Carmen BECKER, Corinna FEIGENBUTZ, Katharina FISCHER, Anette FUHR, Bettina GANTERT, Camille HUG, Carine LEON, Catherine ROHN INFOBEST Vogelgrun/Breisach Ile du Rhin - F-68600 Vogelgrun Tel : +33 (0)3 89 72 04 63 http://www.infobest.eu
Concept et pilotage du projet / Konzept und Projektleitung Carine LEON, INFOBEST Vogelgrun/ Breisach
Pour savoir plus sur l’immatriculation des véhicules/ Mehr Informationen über die Ummeldung von Fahrzeugen INFOBEST Vogelgrun/Breisach, Palmrain, Kehl/Strasbourg, Pamina http://www.infobest.eu/
Les informations qui suivent ont été recueillies et traduites de manière consciencieuse. Néanmoins, il est à noter que d’éventuelles erreurs ne peuvent être exclues et les législations en vigueur peuvent changer. Die nachfolgenden Informationen wurden sorgfältig zusammengestellt und übersetzt. Dennoch können Irrtümer nicht ausgeschlossen werden, und die rechtlichen Bestimmungen können Änderungen unterliegen. Reproduction et adaptation interdites sauf autorisation du SIVOM Pays de Brisach Nachdruck nur mit ausdrücklicher Genehmigung des SIVOM Pays de Brisach. Dépôt légal : octobre 2009 / Gesetzlicher Stand : Oktober 2009
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DEMANDE DE CERTIFICAT D’IMMATRICULATION D’UN VÉHICULE
N° 13750*01
Articles R. 322-1 et suivants du code de la route Veuillez cocher la case correspondante :
FCertificat
FDuplicata FCorrection FChangement de domicile FChangement d’état civil ou d’état matrimonial FChangement des caractéristiques techniques du véhicule VÉHICULE (A) Numéro d’immatriculation actuel
Date d’achat, le cas échéant
(B) Date de 1ère immatriculation
(I) Date de certificat actuel (si ancien format d’immatriculation)
Numéro de formule du certificat d’immatriculation * (si nouveau format d’immatriculation)
DEMANDEUR Personne physique F
Sexe : M F
FF
Personne morale F
Titulaire NOM DE NAISSANCE et PRÉNOM ou RAISON SOCIALE pour une personne morale
NOM D’USAGE (facultatif) : nom d’époux (se)
N° SIREN, le cas échéant
Né(e)
à Jour
Mois
Année
Commune
Département
Pays
Dans le cas de multi-propriété, veuillez indiquer le nombre de personnes titulaires du certificat d’immatriculation Co-titulaire le cas échéant
NOM DE NAISSANCE et PRÉNOM ou RAISON SOCIALE pour une personne morale
NOM D’USAGE (facultatif) : nom d’époux (se)
Si véhicule pris en location, cocher la case correspondante : Véhicule en location courte durée FVéhicule en location longue durée F En cas de location longue durée, merci de préciser :
RAISON SOCIALE DE LA SOCIÉTÉ DE LOCATION, si différente du titulaire
N° SIREN
NOM et PRÉNOM ou RAISON SOCIALE DU LOCATAIRE
N° SIREN, le cas échéant
Domicile (si location, veuillez indiquer le domicile du locataire)
N° de la voie
Extension (bis, ter, .) Type de voie (avenue, etc.)
Nom de la voie
Complément d’adresse (Etage, escalier, appartement - Immeuble, bâtiment, résidence - Lieu-dit - Boîte postale)
Code postal
Commune
CARACTÉRISTIQUES TECHNIQUES COULEUR DOMINANTE (Veuillez cocher les cases correspondantes)
Marque (D.1)
Type variante version (D.2) 0 FClair
Dénomination commerciale (D.3)
Numéro d’identification du véhicule (E)
Genre national (J.1)
1 FFoncé
Numéro d’exploitation agricole, le cas échéant
CADRE RÉSERVÉ A L’ADMINISTRATION Vu les pièces justificatives F F
Rejet de la demande Motif :
0
F
Noir
5
F
Vert
1
F
Marron
6
F
Bleu
2
F
Rouge
7
F
Beige
3
F
Orange
8
F
Gris
4
F
Jaune
9
F
Blanc
La loi n° 78-17 du 6 janvier 1978 relative à l’informatique, aux fichiers et aux libertés, garantit un droit d’accès et de rectification des données auprès d’une préfecture ou auprès de l’Agence nationale des titres sécurisés par voie postale. Je m’oppose à la réutilisation de mes données personnelles à des fins de prospection commerciale F Fait à : .............................................................. Le : Jour
Usage (veuillez cocher la case correspondante) :
Mois
Année
SIGNATURE DU DEMANDEUR
Oui FNon F
(Pour les sociétés : nom, qualité du signataire et cachet)
Mode d’expédition du titre : Voie postale F * Ce numéro figure sur la 1
Retrait à l’Imprimerie Nationale F ère
page du certificat d’immatriculation sous la mention «Certificat d’immatriculation».
20
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cerfa N° 13750*01
Antrag auf Zulassungsbescheinigung eines Fahrzeuges Artikel R. 322-1 ff der Straßenverkehrsordnung Bitte kreuzen Sie das entsprechende Kästchen an Bescheinigung
Durchschlag
Umschreibung
Veränderung des Personenstandes oder des Familienstandes
Wohnsitzwechsel
Veränderung der technischen Besonderheiten des Fahrzeuges
FAHRZEUG
(A) Aktuelles Nummernschild
Ggf. Kaufdatum
(I) Datum des aktuellen Fahrzeugbriefes
(B) Datum der Erstzulassung
Nummer der Zulassungsbescheinigung (wenn es sich um ein neues Format der Zulassung handelt)* ANTRAGSTELLER Natürliche Person
Geschlecht:
M
F
Juristische Person
Inhaber GEBURTSNAME und VORNAME oder NAME der FIRMA
FAMILIENNAME
FIRMENNUMMER(SIREN Nr.) in Tag Monat Jahr Geburtsdatum
Gemeinde
Departement
Land
Anzahl der Personen bei mehreren Eigentümern
MitInhaber GEBURTSNAME und VORNAME oder NAME der FIRMA
FAMILIENNAME
Bei einem Leasing kreuzen Sie die entsprechenden Felder an:
Kurzzeitleasing
Langzeitleasing
Bei Langzeitleasing geben sie bitte an: FIRMENNAME DES LEASINGGEBERS (wenn dies nicht der Inhaber ist)
FIRMENNUMMER (SIREN Nr.)
NAME und VORNAME bzw. NAME der FIRMA des Leasinggebers
FIRMENNUMMER (SIREN Nr.)
Wohnort (Bei Leasing, Wohnort des Leasingnehmers) Nummer
Zusatz
Straßenart (Allee, Weg, etc.)
Straßenname
Adresszusätze Postleitzahl
Gemeinde
TECHNISCHE MERKMALE HAUPTFARBE (Bitte kreuzen Sie die entsprechenden Kästchen an) Marke (D,1) Typenbezeichnung (D,2) Handelsbezeichnung (D,3) Identifizierungsnummer des Fahrzeuges (E)
Nutzungsart (J,1)
Nummer des landwirtschaftlichen Betriebs, falls dies auf sie zutrifft NUR VON DER VERWALTUNG AUSZUFÜLLEN Vu des pièces justificatives Rejet de la demande
Gemäß dem französischen Gesetz n° 78-17 vom 06. Januar 1978 in Bezug auf Informatik, Datenblätter, und persönliche Freiheit, haben Sie das Recht Zugang zu diesen persönlichen Daten zu haben und diese bei einer Präfektur zu verändern F Ich verweigere eine Verwendung meiner persönlichen Daten zu kommerziellen Zwecken
Motif: Mode d’expédition du titre :
Ort :………………………………….. Datum : voie postale
Retrait à l’imprimerie Nationale
Tag
Monat
Jahr
Unterschrift des Antragstellers Bei Firmen Name, Funktion und Firmenstempel
21
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www.infobest.eu
Neustadt Landau Dahn
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Karlsruhe
Wissembourg
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Baden-Baden Saverne Strasbourg Molsheim M
Offenburg
BADENWÜRTTEMBERG
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Emmendingen
Colmar Freiburg
Mulhouse Lörrach
Waldshut
Altkirch Basel Liestal Aarau Delémont
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Réalisation : Friedling Graphique - Kaysersberg/Rixheim - Certifié Imprim’Vert
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Crédit photo : Fotolia
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